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2 Healthcare Reform and Ryan White Programs: The Basics Under the Patient Protection and Affordable Care Act (ACA), millions of people with HIV/AIDS who are now dependent on Ryan White programs, including the AIDS Drug Assistance Program (ADAP), will become eligible for Medicaid or subsidies to purchase commercial health insurance. 1 This change raises new issues about continuity of care for people with HIV/AIDS and the role Ryan White programs may play in the future. Two vehicles for expanding coverage Beginning January 1, 2014, about 8 million people will enroll in Medicaid. 2 In states that choose to expand Medicaid, eligibility will no longer be based on such considerations as whether a person is disabled or has children. Rather, income will be the sole determinant factor 3 eliminating a coverage gap that currently exists for many individuals with HIV/AIDS. US citizens, as well as immigrants who have legally resided in the US for more than 5 years, will qualify for Medicaid benefits 3,4 if their incomes do not exceed 138% of the federal poverty level (FPL) (about $15,000 per year for an individual 5 ). In some states, income thresholds may be higher. For low-income people unable to take advantage of Medicaid expansion, new federal subsidies and tax credits can help those with incomes between 100% and 400% of FPL (up to about $46,000) purchase coverage through health insurance marketplaces. 6 Coverage is guaranteed, regardless of health status. 7 Shift in how people get care These changes are not expected to introduce many new people with HIV/AIDS into the healthcare system. Rather, they shift how patients will get their care. Nearly 6 in 10 people who are HIV-positive and who get services through ADAP will qualify for Medicaid more than 85,000 people if the program were to expand in each state. 4 As many as 77,000 uninsured people with HIV/AIDS may qualify for marketplace subsidies, depending on the number of states that do not expand Medicaid. 4 2

3 ADAP clients, by income 4 The top 10 states in terms of number of ADAP clients, as well as the share of those who may become eligible for Medicaid, are shown on page 6. Why is this important? Many people with HIV/AIDS rely on a patchwork of safety net programs for basic care and medications. Medicaid expansion and marketplace subsidies offer these patients an opportunity to gain access to more comprehensive care. This shift also raises the possibility that Ryan White programs and ADAP assistance 2 services that are historically underfunded 1,8 and overburdened 9 can be refocused to work in tandem with access reforms to improve the care of people with HIV/AIDS. For patients with new insurance coverage, Ryan White programs and ADAP may help to assure continuity of care by filling gaps in patients new benefits 10 or assisting with out-of-pocket expenses. 11 In states that do not expand Medicaid, however, these programs may face new hardships. 1 Both scenarios will be important considerations as Congress considers reauthorization of Ryan White programs. 3

4 Pivotal Issues for Ryan White Programs/ADAP Going forward, Ryan White programs and ADAP can still play important roles for people with HIV/AIDS. Those roles, however, may hinge on how the implementation of healthcare reform plays out. Supreme Court ruling on Medicaid expansion A 2012 Supreme Court ruling on the constitutionality of the ACA allowed states to opt out of Medicaid expansion. 1 This situation is in flux, and some states that initially declared an intention to not expand Medicaid may yet do so, now or after January 1, 2014 or may choose to not expand at all. 12 In states not expanding Medicaid, a substantial number of people may remain uninsured because of an inability to afford commercial coverage. The ACA does not provide subsidies to people with incomes 100% FPL ($11,490 for an individual 5 ) to buy insurance through the marketplaces. 13 About 45% of ADAP clients have incomes 100% FPL. 4 Many of the states that oppose Medicaid expansion are in the South. The number of ADAP clients in Southern states, as well as the share of those who may not benefit from Medicaid expansion, is shown on page 6. Intersection of Ryan White programs and healthcare reform Because Ryan White programs are the payer of last resort, providers of Part A services coordinate with public and private insurers on the provision of benefits. 10 Even after patients transition to new coverage, Ryan White programs may provide wraparound coverage for patients with insurance who still have gaps in coverage. 14 Each state develops its own rules for interacting with safety net programs. Depending on a state s eligibility requirements, some people who gain coverage through marketplaces may still receive co-payment and premium support or other benefits from Ryan White programs, 14 while others may not be eligible for benefits through Ryan White programs at all. Patients in states that do not expand Medicaid and who cannot afford private insurance could still qualify for benefits from Ryan White programs, depending on the outcome of reauthorization proceedings. Relevant issues to watch for during these discussions include the types of patients who can access services, the services that are provided, and the degree of flexibility maintained in the programs so that care for people with HIV/AIDS is not compromised as healthcare reform implementation proceeds. 1,14 4

5 Intersection of ADAP assistance and healthcare reform ADAP benefits may still be available to some people who transition to Medicaid, even in states with more generous eligibility standards than the federal income requirements. Other states may terminate ADAP assistance for people who obtain Medicaid benefits. Because Medicaid expansion has the potential to move people out of ADAP, Medicaid conversions may free up ADAP benefits for others. In states that do not expand Medicaid, however, some of the burdens that have traditionally plagued the program, such as waiting lists and caps on assistance, 1,9 may recur. ADAP assistance may be available to low-income patients who obtain commercial coverage through marketplaces, providing premium support and co-payment assistance. 11 Depending on the state, ADAP may also provide enrollees with access to antiretroviral (ARV) drugs not on a commercial plan s formulary. While federal law requires that marketplace-based plans provide prescription drug coverage, 15 there is little specificity about states formulary requirements. 16 The Department of Health and Human Services did not require states to adopt the Medicare Part D standard that substantially all ARVs be covered. 1,15 Funding for ADAP will be a focus of discussions on reauthorization of Ryan White programs. Sequestration had previously threatened ADAP funding and Part B grants to states. Continued federal budget pressures have the potential to create new hardships on ADAP services in states that are not expending their Medicaid programs. Though many people with HIV/AIDS who now rely on safety net programs may obtain new healthcare coverage through Medicaid expansion and marketplace subsidies, experts agree that healthcare reform does not eliminate the need for Ryan White programs. 1 5

6 Calculating the Migration of Patients From ADAP to Medicaid Top 10 states with potential for conversion, by volume of ADAP clients (June 2012 data) 4 People with incomes 138% FPL qualify for Medicaid in states expanding their programs. Some states have raised eligibility levels above 138% FPL. People with incomes <100% FPL are ineligible for marketplace subsidies. State June 2012 Clients Served <100% FPL 101% 138% FPL California 26,253 41% 11% Florida 12,005 48% 17% Illinois % 11% Maryland % 13% Massachusetts % 9% New Jersey % 11% New York 16,477 33% 11% North Carolina % 20% Pennsylvania % 12% Texas 10,881 52% 13% 6 Current as of January Potential Southern state conversions, by volume of ADAP clients (June 2012 data) 4 Most of the states that have declared their intention to not expand Medicaid are in the South. Some of the states below initially declined to expand Medicaid, though the situation remains fluid. State June 2012 Clients Served <100% FPL 101% 138% FPL Alabama % 37% Arkansas % 18% Florida 12,005 48% 17% Georgia % 40% Kentucky % 100% Louisiana % 0% Mississippi % 0% North Carolina % 20% Oklahoma % 0% South Carolina % 10% Tennessee % 8% Texas 10,881 52% 13% Virginia % 14% West Virginia % 30% Current as of January 2013.

7 Practice Considerations Any shift in coverage often brings changes in covered services, drug therapy choices, and healthcare providers. Whether you are a provider of Ryan White programs, a primary care physician, or a specialist in HIV/AIDS care, patient conversions from Ryan White programs to Medicaid or commercial coverage may affect your practice. The evolving relationship between Ryan White programs and new coverage options may impact your patients. Depending on events in your state, consider the following: ADAP may provide benefits when other healthcare options are unavailable. In many cases, conversion to Medicaid ends ADAP benefits, though in some states, some wraparound benefits may still be available to those with gaps in coverage. For patients who convert from ADAP to Medicaid, patients may have more or fewer choices of HIV drugs, depending on the state. 1,9 After converting to Medicaid or commercial coverage, patients may experience co-payments, deductibles, and other cost-sharing techniques. 14 If you are a Ryan White clinic, what will your role be in 2014? Many Ryan White clinics are pursuing federally qualified health center (FQHC) status, allowing them to contract and interact with Medicaid programs. 17 Ryan White clinics with FQHC status may retain patients who convert to Medicaid. They may also be able to provide access to care for those who may be unable to get timely care because of shortages of providers who accept new Medicaid patients. When patients are forced to change providers, watch for gaps in care. For patients obtaining new coverage, treatment options could change depending on the new payer s benefit structure, formulary, and provider network. 1 Let your Janssen Therapeutics Account Manager be an information resource for you on how healthcare reform may impact access and care for people with HIV/AIDS. 7

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